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Based on record review, interview, policy review and Centers for Disease Control (CDC) coronavirus guideline review, the facility failed to ensure a patient who tested positive for Covid-19 was isolated to prevent the spread of infection and failed to ensure the infection control policy addressed how to segregate patients positive for Covid-19 (A0749). This affected two (Patients #10 and #11) of 20 sampled patients. This had the potential to affect all patients in the facility. The census was 72.

Based on record review, interview, policy review and Centers for Disease Control (CDC) coronavirus guideline review, the facility failed to ensure a patient who tested positive for Covid-19 was isolated to prevent the spread of infection and failed to ensure the infection control policy addressed how to segregate patients positive for Covid-19. This affected two (Patients #10 and #11) of 20 sampled patients. This had the potential to affect all patients in the facility. The census was 72.

Findings include:

Review of the facility's infection control spread sheet revealed Patient #6 and Patient #7, who resided on the Grace Unit, tested positive for Covid-19 on 07/09/20.

A review of facility document "Timeline of events following notification of exposure and positive patient" revealed on 07/08/20, Staff E was notified that Patient #6 and her roommate, Patient #7, had tested positive for Covid-19. As both patients were on the Grace Unit, that unit was closed and quarantined. Staff were notified and screening precautions were increased. Temperatures were taken every four hours, the frequency of cleaning frequently touched surfaces cleaning was increased to every four hours, and gowns, masks, shoe coverings and other personal protective equipment was provided to staff to don prior to entering the unit. The local health department was contacted on 07/09/20 and testing for the remaining patients was requested.

On 07/11/20, all remaining patients were tested for Covid-19. Results returned on 07/13/20 revealed Patients #10, #12, #15 and #20 had tested positive for Covid-19. Patient #11 tested negative. Patient #10 and Patient #11 were roommates. There was no documentation any effort was made to transfer Patient #11 out of the room or to move Patient #10 into a room with another Covid-19 positive patient. Review of the census for the Grace unit for 07/13/20 revealed there were empty beds available.

Review of Patient #11's clinical record revealed he remained in the same room with Patient #10 until his discharge on 07/15/20.

On 09/15/20 at 11:15 AM, Staff E confirmed Patient #10 and Patient #11 were not separated after discovering Patient #10 was positive for Covid-19, Management believed all patients on the unit were Covid-19 positive.

A review of the facility's policy titled "2020 COVID Patient and Staff Exposure Reduction Plan" contained no documentation on procedures for placement for patients, i.e., cohabitating patients with the same Covid-19 test results or whether and how to segregate the Covid-19 positive patients from the negative ones.

.A review of Center for Disease Control guidelines for health care workers at https://www.cdc.gov/coronavirus/2019 revealed to place a patient with suspected or confirmed Covid-19 infection in a single person room with the door closed.